Thursday, November 17, 2005

"No Patient Left Behind"

I have been doing a lot of consulting in healthcare information systems. I'm happy about this work for several reasons: it is interesting in both technical & sociocultural dimensions, in fact, most of the impediments to the evolution of these systems are not technical, but rather cultural & political. This shouldn't be a surprise... Also, I think it is critical work. Improvement in medical information systems is, I believe, one of the things that could most help our healthcare system. David Harrington, VP & CTO of MedicAlert (the 'bracelet company'), asked me to be on a panel at the Healthcare in the 21st Century Workshop held in Alexandria, VA on 25-27 October 2005. There were several keynote speakers including Janet Marchibroda of the eHealth Initiative (a non-profit advocacy group) & Robert Kolodner from the Veteran's Administration There was one consistent theme in the evolution of healthcare that was quite distressing (to me). All of the keynote speakers, & every person from either the Government or the payers (insurance companies) that spoke agreed that value-based purchasing was going to be instituted in various ways over the next few years in healthcare & that it would change the way healthcare was delivered, administered & paid for. This is a polite way of saying pay-for-performance. There are several ongoing efforts to develop a set of between 100 & 200 criteria that provider performance would be evaluated against. These range from financial metrics to medical criteria (like how often beta blockers are administered after myocardial infarction). Each 'pay incident'” (doctor's visit, emergency room treatment, planned medical procedure, etc.) would be evaluated against these criteria & a dollar reimbursement amount would be determined. Poor 'performance' would result in lower fees. Of course, the rub is that we know from painful experience that you get what you measure, so the expectation is that healthcare delivery would evolve to address these metrics - think '“No patient left behind' (sorry, that was a value judgment.). If this actually happens, & again, every speaker felt it was a matter of when not if, it will substantially change not only the business models for healthcare provision, but also its delivery. Clinicians & providers of all types: hospitals, laboratories, clinics etc., will be evaluated with respect to a set of criteria developed & administered by governmental, non-medical, entities. I can think of few impediments to the true improvement of our healthcare system than this.

Much of the Workshop was devoted to exploring new models in healthcare delivery - the primary focus of this exploration was in discussing current experiences with healthcare information sharing, mainly in the entities called Regional Healthcare Information Organizations or RHIOs. These are sociopolitical organizations that agree to use technology to share clinical, demographic & financial information about patients across a region, such as a county or other bounded geography. The idea is that information is provided at the point of care, regardless of where it comes from across the system. You show up at the emergency room of a hospital in your area that you have never been seen at before, & all of your clinical & relevant personal information is available to the treating clinician. I know, there are a lot of potential privacy & other issues with this - topics for another post... I have been advising on the technology of such a system in Santa Barbara County (CA) for the California Healthcare Foundation (CHCF, This system is called SBCCDE (Santa Barbara County Care Data Exchange, The development of the CDE software was funded by the CHCF & the system is deployed & should be in active use by the end of this year. There are several RHIO efforts ongoing in Massachusetts. See the material on MA-Share ( Much of the discussion at the Workshop was about the possibilities of success for the RHIO & associated models. The consensus was that doing the right thing would not be enough to ensure success. Healthcare information sharing organizations would have to be successful businesses. There does not appear to be a consensus on what such a model would be & no RHIOs in this country (that I know of) are currently successful businesses, although there are some in Europe & Israel that appear to be. Do you think that information sharing at any geographic level will improve healthcare delivery? Would you prefer to be responsible for your own medical records yourself & carry a hard disk (USB or otherwise) around with you so that they would be available? Should a neutral broker manage your healthcare records & make them available? Let me know what you think -

Tuesday, September 27, 2005

What color are these glasses?

I spent half of the last two weeks in California working with the California Healthcare Foundation (see the website for current projects), which always prompts the question of "what did I come back for?" Leaving that aside, I was amazed to see that the lead article in the September 20th edition of the small business section in the New York Times was titled "Getting in on the Next Little Thing", by Gary Rivlin & that it was an anecdotal account of high times returning to high-tech venture investing. To be fair, it did have some actual statistics, but for the most part it described several small company's highly positive experiences in the current (West Coast) venture environment. I spent 1999-2001 doing consulting for technology companies in the Bay Area & Silicon Valley (as CTO for Upstream Consulting), so I experienced the VC thing of the dot-com boom first hand. I am currently looking for zero stage funding for a company here in the Boston area, so I am experiencing the angel funder & VC thing of this era (no name yet?) here first hand - All I can say is "What is Gary Rivlin smoking?"

I remember 1999. I remember sitting in Upstream's offices in Emeryville, CA interviewing a prospective client. This was a 36 year old (i.e old) CEO whose last company was failing largely because of him & his management team, & who was being put in place as CEO of a newly funded company in a similar segment by the VCs. My business partner (John Rymer, now a Research VP at Forrester Research) asked him what his business plan for the new company was. His reply was immediate - "World domination". That company failed too, but not before about $26M had been funneled into it. In 1999 there were 1009 IPOs with a total amount of capital raised of about $115B (all figures from Remember ICG that opened at $12, & closed the year at $170 for a 2733% gain or my personal favorite (I was CTO there two years later), Agile Software that opened at $21 & closed the year at $217 for a 934% gain? Last year (2004) there were 360 IPOs that raised a total of $44.5B. The biggest gainer was not Google, which opened at $85 at closed the year at $184 for a 117% gain, but 51jobs, a Chinese human resource & recruiting speciality firm that publishes newletters to connect the parties in hiring process. It opened at $14 & closed the year at $52.5 for a 275% gain. The average gain of the top 25 IPOs in 2004 was 130% - the average gain of the top 25 IPOs in 1999 was 1300%. It's not 1999 anymore.

In the first half of 2005 there were 91 venture-backed IPOs which raised ~$28B. It's really not 1999 anymore. Which brings me to my recent experience. I have been trying to raise zero stage money for a software & services company for about the last 4 months. I have been talking with groups who do angel funding & zero stage VC companies. The company is in a hot area with a technology that I know well and was one of the early developers of. I have a local company that has agreed to do a product prototype with us & to support the development in kind (contribute their people's time as well as server & software access). The funders have been telling me several things:

Thing1: We realize that you have yet to build the product, but please tell us in detail the specific value proposition, the business plan including hiring plan & budget, the expected return on investment for both the investors & customers & any metrics you can suggest or evidence for your assumptions.
Thing 2: It's interesting that this company will allow you to do a prototype, but why aren't they paying in full for its development. Don't they think it's worth the investment? If they don't, why should we?
Thing 3: We understand that your plan calls for 2000 additional effort-hours of development above what you do for this company, but if they did pay for their part of the development work, why would you need an investment from us?
Thing 4: If we did invest, we would need to get all of our investment back plus a return when we sell your "stock" to the Series A funder. We would want a 150-200% return.

Most of this is a win for them, lose for me proposition. I was the fifth person into Riverton Software in 1995. We went from that to shipping two product versions & over 200 customers in 24 months, but we did not have a 200% return. The chance of any zero state start-up doing this these days is slim. The company Gary Rivlin wrote about, that had VCs chasing them, was 18 months old & had shipped two versions of their product - hardly a zero state venture. Maybe I should ask Gary Rivlin to invest... stay tuned.

Tuesday, September 06, 2005

New Website - New Posting...

That was pretty "quasi-periodic", given that this is my second post in 8 months. No website, so new blog postings. I'll try for once a week...

Lot's of changes in the past 8 months. The last time I posted, I was sitting in the Starbucks in Arlington, MA. Today, I'm sitting in my office in the Engineering Systems Division (ESD) at MIT (E40-264, 617-324-6693). I'm part time here at ESD & will be helping to team teach the ESD Doctoral Seminar with my colleague Joel Cutcher-Gershenfeld & also helping to team teach the new Sloan Undergraduate course with my friend/colleague Tom Kochan. This is exciting & I'll be posting on my opinions about things at MIT quite a lot here. Courses start this week & I'll be trying to balance my time between this work, my consulting work (see website) & writing the book I'm committed to, both contractually & emotionally (also see website).

Here's an MIT opinion... One of the programs I've gotten involved with is the Program on Emerging Technologies or PoET. This is a degree-granting program that is a collaboration between the School of Engineering & the School of Humanities, Arts & Social Sciences involving ESD, the Technology & Policy Program, the Center for International Studies, the Department of Political Science & the program in Science, Technology & Society. The program looks at the economic, security, environmental & socio-cultural implications of emerging technologies & assumes that our understanding of these implications does not & can not keep up with the actual development of technologies. It is exactly the kind of program I have been talking & writing about for years as being essential in the education of technologists - So why did I feel so out of place in the meetings? I literally felt uncomfortable as the kind of focus I've been emphasizing for years was played out. Emerging technologies is what I do, right...? Part of it was that I have been doing this in a corporate setting for the past 20+ years. Where emerging technology is dealt with at all in this context, it is looked at as a potential revenue source, an addition to the strategic product portfolio to be developed or acquired as the numbers indicate. The economic implications are narrowing analyzed with respect to the bottom line & the other implications are left as an exercise to the user. Part of it was that in my corporate setting, many of the people dealing with these topics were programmers or managers of programmers. These people are generally not focused on the larger socio-cultural aspects of their work. Sitting around the PoET table are political economists, historians of science & technology, technological theorists & academic technologists across the spectrum from network theory to bioengineering, as well as some very bright & accomplished students. A very different environment from the Emerging Technology Committee at EMC (my last corporate employer). Suffice to say, I am getting more comfortable with my PoET colleagues & am looking forward to learning & teaching in this program.

& speaking of emerging (or emerged) technologies & their implications, my next focus for the FutureSense Strategist is search. The next issues of the strategist is entitled "If Search is the Answer, What's the Question?" (with respect for Danny Bobrow at PARC for his original paper on Prolog, one of the two best papers I know of in AI languages). Search is driving quite a lot of research & development activity these days & creating a lot of value for companies such as Google (for instance), but what really are the longer-term implications & consequences of this effort. What can search actually do for us in our everyday efforts, both at work & "in real life" (for those of you that have them...). This next Strategist will focus on the larger picture of search & its place in our work & life processes - due at the end of September...

Enough for now... Look at the new website ( &:

remember - entropy requires no maintenance

Thursday, January 20, 2005

Finally... or Post V1.0

OK - Pito Salas finally talked me into trying this. I've been reading many blogs for a while, but not writing, so here goes. As I have been saying in my voicemail for some time, I tend to do things episodically & quasi-periodically, so that's all I'll commit to, quasi-periodic postings on what I thinking about & seeing as emerging technologies are developed & applied to new & existing product streams. I can't & won't separate what I write here from my work as the Founder & Principal of FutureSense Research. This is a boutique research & consulting firm that works with companies to facilitate the exploration & integration of emerging technologies into new & existing software product streams. It's what I do...

This is the second time I have started FutureSense. The first was in California in 2001, a difficult time to start a one-person consulting shop. FutureSense did well then & I expect it will now, mainly because not many people really focus on emerging technologies & how they can or even should be integrated into products that companies rely on. This blog is more about the concepts/trends/ideas involved & not the mechanism (the consulting company). OK - enough of that...

I am just leaving the EMC Corporation where I was a Technology Vice President responsible for the concepts, strategy & product architecture in the collaboration product space. I got to EMC through a series of acquisitions; I was CTO at eRoom Technology when Documentum bought eRoom & then EMC bought Documentum. I've work at LARGE companies (Digital Equipment, General Motors, Boeing) & small companies (Riverton Software, Upstream Consulting, eRoom Technology) & prefer small, hence my exit from EMC. I'm also not a big fan of M&A, having been through several that were consummated & at least one that was not (Agile Software/Arriba, Inc.). That's fuel for another entry though...

The next couple of posts will be about things I'm doing now: writing a book on the co-evolution of technology & organizations & how that effects our idea of work, developing some new ideas on how to make business process design & execution much more effective & continuing to evolve my ideas about current & near-future technology trends. I'm sure that I also won't be able to keep from commenting on the more or less interesting things happening in the technology universe. Stay tuned (whoever you are...)